This document summarizes presentations from the FCIC Survivorship Conference in 2013 on fear of cancer recurrence. It discusses how fear of recurrence is a major unmet need for cancer survivors, with 40-70% reporting clinically significant fear. Traditional cognitive behavioral therapies are limited in addressing the origins and existential challenges of fear of recurrence. A novel intervention was piloted that aims to help patients assign less importance to fears by developing life goals and meaning, showing reduced fear, distress, and improved quality of life. A future randomized controlled trial is proposed to further evaluate this approach.

1. FCIC Survivorship Conference. Adelaide. 2013.
FEAR OF RECURRENCE
Jane Turner
University of Queensland

2. FCIC Survivorship Conference. Adelaide. 2013.
THE DIAGNOSIS OF CANCER
Often unexpected - never convenient!
Emotional distress and fear
Stress of decision-making
Burden of disease/treatment side-effects
Challenge to sense of self
Rekindling past experiences of grief and
loss

3. FCIC Survivorship Conference. Adelaide. 2013.
COMPLETION OF
TREATMENT
Often anticipated as being the time to breathe
again and reclaim life
But the reality is:
 Facing a “new normal” and adjustment in terms of
goals and expectations
 Abrupt disconnection from the treatment team
 Evaporation of practical and emotional support
 Lack of clarity about the goals of follow-up
 Disconnection from those who aren’t members of
“the club”
 Tempered by social expectations and pressure to
conform/“think positive”

4. FCIC Survivorship Conference. Adelaide. 2013.
FEAR OF CANCER
RECURRENCE
“The fear that cancer could return or
progress in the same place or another part
of the body” Vickberg 2003
Transient FCR almost invariable, however:
 40 to 70% of cancer survivors report clinically
significant FCR Thewes et al 2009
 FCR identified as one of the greatest unmet needs
of cancer survivors Hodgkinson et al 2007
4

5. FCIC Survivorship Conference. Adelaide. 2013.
Patients with high FCR:
 Reported to be less satisfied with
their care
 More likely to refuse discharge from
a cancer centre for follow-up
 More likely to seek readmission to a
specialised cancer centre
Hart et al 2008;
Glynne-Jones et al 1997

6. FCIC Survivorship Conference. Adelaide. 2013.
Web-based survey completed by 218 women
diagnosed with early stage breast cancer at least
one year earlier
 70% reported clinically significant levels of FCR
 High FCR associated with:
o Higher frequency of unscheduled visits to GP
o Higher frequency of breast self-examination
o Not having mammograms or ultrasounds or other
forms of screening in the past year
o More use CAM
o More use of counselling and support groups
Thewes et al 2012

7. FCIC Survivorship Conference. Adelaide. 2013.
FCR AND HEALTH
PROFESSIONALS
Survey of:
 76 psycho-oncology health professionals
 47 oncologists and nurses
o 30% reported FCR was an issue for more than
half their patients
o 31% of doctors reported spending more than
25% of the time in follow-up consultations
discussing FCR
o 46% found dealing with FCR challenging
o 71% were interested in further training in how to
manage FCR PoCoG 2010

8. FCIC Survivorship Conference. Adelaide. 2013.
TRADITIONAL APPROACHES
TO DISTRESS
Cognitive behaviour therapy:
 Aims to:
o Help identify unhelpful thoughts and behaviours
o Develop skills to challenge cognitive
distortions, selective abstraction etc.
 Fails to:
o Acknowledge the clinical reality and uncertainty
about prognosis
o Help the person understand the origins of
maladaptive patterns of thinking and behaving
o Help the person respond to existential
challenges

9. FCIC Survivorship Conference. Adelaide. 2013.
A NOVEL INTERVENTION
The novel intervention addresses core
themes pertinent to the person who has
experienced cancer
Aim of this intervention is not to get rid of
worries about recurrence completely:
 To help people with high FCR to assign
less importance and less attention to
this concern
 To develop goals for the future which
will give their life purpose, meaning and
direction

10. FCIC Survivorship Conference. Adelaide. 2013.
PILOT STUDY RESULTS
Demographic details N (%)
Gender (Female) 8 (100%)
Relationship status
 Married/defacto
 Divorced/separated
6 (75%)
2 (25%)
Educational attainment
 High School
 TAFE/University
5 (62%)
3 (38%)
Employment
 Employed
 Retired/pensioner
7 (88%)
1 (12%)
Country of birth
Australia 6 (75%)
Children
Yes 7 (88%)

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Mean (range)
Age at diagnosis (years) 49 (37 – 64)
Time since diagnosis (years) 2.3 (0.8 – 4.5)
Disease & treatment details N (%)
Cancer type
 Breast
 CNS lymphoma
 Hodgkin’s lymphoma
 Endometrial/kidney cancer
5 (64%)
1 (12%)
1 (12%)
1 (12%)
Treatment
 Surgery
 Chemotherapy
 Radiotherapy
 Hormone Therapy
 Herceptin
7 (88%)
8 (100%)
6 (75%)
3 (38%)
3 (38%)
Currently receiving hormone treatment 3 (38%)

12. FCIC Survivorship Conference. Adelaide. 2013.
FCR SEVERITY
 of 8.2 points on the 36-point Fear of Cancer Recurrence
Inventory (FCRI) Severity Subscale;
p = 0.002, effect-size 1.9
FCRSeverity
0
10
20
30
40
Baseline Post intervention Two-month follow-up

13. FCIC Survivorship Conference. Adelaide. 2013.1
 of 13.0 points on the 100-point FACT-G;
p = 0.2, effect-size 0.67
QUALITY OF LIFE
QualityofLife
40
50
60
70
80
90
100
Baseline Post intervention Two-month follow-up

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DISTRESS
of 17.7 points on the 75-point IES;
p = 0.03, effect-size 1.2
ImpactofEvents
0
10
20
30
40
50
60
Post intervention Two-month follow-upBaseline

15. FCIC Survivorship Conference. Adelaide. 2013.
REDUCING FEAR OF CANCER RECURRENCE IN
BREAST AND COLORECTAL CANCER SURVIVORS:
A CLUSTER RANDOMISED CONTROLLED TRIAL
Investigators Affiliation
Phyllis Butow University of Sydney
Belinda Thewes University of Sydney
Jane Turner University of Queensland
Jemma Gilchrist Westmead Cancer Care Centre
Jane Beith Sydney Cancer Centre
Afaf Girgis University of NSW
Louise Sharpe University of Sydney
Melanie Bell University of Sydney
Funded by Cancer Australia

16. FCIC Survivorship Conference. Adelaide. 2013.
METACOGNITIONS AND
DISTRESS
Self-regulatory Executive Function model identifies
several inter-related components of cognition
linked to the development and maintenance of
emotional disorder Wells and Matthews 1994
Cognitive attentional syndrome (CAS)
1. Self-focused attention
2. Worry and rumination
3. Attentional bias towards threat-related information
4. Coping behaviours that are maladaptive (e.g.
suppression, avoidance, minimisation) because they
impair flexible self control or prevent corrective
learning experiences

17. FCIC Survivorship Conference. Adelaide. 2013.1

18. FCIC Survivorship Conference. Adelaide. 2013.
5 sessions, each lasting 60 to 90 minutes
Delivered one-on-one by trained psychologist/psychiatrist
Session 1:
 Detailed psychosocial history
 Exploration of existential issues, vulnerability factors
 Values clarification and goals
Session 2:
 Explanation of development of FCR
 Introduction to Attention Training Technique (ATT)
Session 3:
 Introduction to detached mindfulness, worry postponement
 Reinforce ATT
Session 4:
 Introduction to realistic health care and strategies to enhance wellness
 Review of unhelpful practices
Session 5:
 Review of goal-setting and skills

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Aim to recruit 324 patients who have completed
treatment for breast or colorectal cancer more
than 2 months but less than 5 years ago
Measures at baseline, completion of treatment, 3
months and 6 months
Primary outcome:
 Fear of Cancer Recurrence
Secondary outcomes:
 Cancer-specific distress
 Quality of life
 Economic analysis

20. FCIC Survivorship Conference. Adelaide. 2013.
IN SUMMARY
Fear of recurrence poses a
considerable unmet burden
Traditional interventions fail to
address key issues
Emerging conceptualisations offer
promise
Watch this space!